Healthcare Provider Details

I. General information

NPI: 1093723207
Provider Name (Legal Business Name): MICHAEL JOSEPH WITT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALCAN ROLLED PRODUCTS CENTURY ROAD
RAVENSWOOD WV
26164
US

IV. Provider business mailing address

11 RIDGEVIEW DR
MULLENS WV
25882-1615
US

V. Phone/Fax

Practice location:
  • Phone: 304-273-6261
  • Fax: 304-273-6549
Mailing address:
  • Phone: 304-294-2625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number864
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: